Μαρία Μπόνου Διευθύντρια ΕΣΥ, ΓΝΑ Λαϊκό

Μαρία Μπόνου Διευθύντρια ΕΣΥ, ΓΝΑ Λαϊκό

Diastolic HF DD: Diastolic Dysfunction DHF: Diastolic HF HFpEF: HF with preserved EF DD Pathophysiologic condition: impaired relaxation, LV compliance, LV filling pressures HFpEF DHF Normal Normal LVEF LVEF plus plus Signs/symptoms of of HF HF not due only to DD due to DD (excluding severe valve disease, constriction etc)

Definition of HFpEF 2016 ESC Guidelines 1. Symptoms ± Signs 2. LVEF >50% 3. Elevated levels of natriuretic peptides (BNP > 35 pg/ml and/or NT-proBNP > 125 pg/ml) 4. At least one additional criterion: a. Relevant structural heart disease (LVH and/or LAE) b. Diastolic dysfunction Eur Heart J 2016;37:2129 2200

Characteristics of patients with HFpEF Older population Female predominant Comorbidities Average: 4 Co-morbid Conditions - Hypertension - Atrial fibrillation - Coronary Artery Disease Eur Heart J 2016;37:2129 2200

HFpEF Comorbitidies

Prevalence of HFpEF 1987-2 0 0 1, 4 5 9 6 p t s w i t h H F Owan et al. N Engl J Med 2006;355:251-9

Mortality is High in HFpEF and Similar to HFrEF EF 50% EF < 50% Owan et al. N Engl J Med 2006;355:251-9

Diagnosis of HFpEF is challenging Echo plays a pivotal role in the diagnosis of diastolic dysfunction Don t miss a non-hfpef cause of HFpEF Non-cardiac causes Anaemia Cardiac causes Hypertrophic cardiomyopathy Infiltrative or restrictive cardiomyopathy Constrictive pericarditis High output heart failure Valvular heart disease Coronary artery disease Pulmonary embolism Right ventricular myopathies

Pathophysiology of HFpEF Diastolic dysfunction Ventricular Arterial (V A) coupling Chronotropic incompetence Abnormal LV systolic function Myocardial stiffness Arterial stiffness Systolic Abnormalities in HFpEF Mitral regurgitation I N F L A M M A T I O N Atrial fibrillation Inadequate increase in heart rate and CO during exercise Diastolic Systolic and Abnormalities Systolic Dyssynchrony in HFpEF is common in HFpEF Echo with TDI Cardiac output reserve Exertional dyspnea and fatigue Activity avoidance Oedema, ascites and cachexia Peripheral limitations Hoeper et al. Eur Heart J 2017; 2869 73

Echocardiographic Assessment of Diastolic Function Transmitral pulsed-wave Doppler Assessment of LV Diastolic Function Mitral annular tissue Doppler E/e : Marker of LV Filling Pressure E/e =27

Echocardiographic Assessment of Diastolic Function PEARLS E/A > 0,8 Normal e for age E DT normal E/A < 0,8 e for age E DT prolonged E/A >0,8 (often >1) e for age Look for: E/e and/or LA size E/A > 1,5-2 E DT < 140 ms e for age A wave and a Mitter et al. JACC 2017;1451-64

Echocardiographic Assessment of Diastolic Function Valsalva maneuver Pulmonary Venous Flow

Special Scenarios for Assessing Diastolic Function and LV Filling Pressures Severe impaired relaxation high LA pressure E/e >11 (septal e ) E/a<1 (LA underfilled) Lateral e is preserved Respiratory variation Septal e lateral e Small E e Falsely E/e

Algorithm for diagnosis of LV diastolic dysfunction 2016 ESC Guidelines Diastolic Stress Testing Heart Catheterization

PATIENT WITH SUSPECTED HFpEF Assessment of HFpEF probability 1. Clinical History : > 60 yr of age Comorbidities 2. Physical examination 3. ECG Natriuretic peptides NT-proBNP 125 pg/ml, BNP 35 pg/ml Cardiac echo: ejection fraction >50% Yes Perform alternative testing(i.e. invasive hemodynamic testing) Are there complicating factors or is image quality poor? (tachycardia, bradycardia, AV block, arrhythmia, MAC, MV prosthesis, any MS, 3+ MR) Check for presence of diastolic dysfunction Average E/e > 14 Septal e < 7 cm/s or Lateral e <10 cm/s No TR velocity > 2.8 m/s LA volume index >34ml/m 2 Consider alternative causes Grade diastolic dysfunction Normal E/A > 0.8 e normal for age Normal LA volume Grade I E/A < 0.8 Reduced e for age LAVI normal or Grade II E/A > 0.8 Reduced e for age LAVI Grade III E/A > 1.5 Reduced e for age LAVI, DT < 140 ms Assess for increased LV filling pressure (LVFP) Diastolic Stress Testing Likely normal Septal E/e' < 8 Lateral E/e < 8 Indeterminate Septal E/e' 8-15 Lateral E/e 8-12 Likely elevated Septal E/e' > 15 Lateral E/e > 12 Inconclusive results H E A R T C A T H E T E R I Z A T I O N

Diagnostic dilemmas in HFpEF T h a n k y o u